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nspection Report Number Waste Tire Su & Ins ectionRe <br /> State of California p6TAk <br /> WHOM <br /> _ A .., <br /> CIWMB181(New 04104) Survey Form - Pagel - � a 2 .- 1 <br /> California Integrated Waste Management Board 0 1 4 $ $ 3 . <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / [7 j �- 0 (b Routine Q Re-inspection Q Referral Q Observation. <br /> Local -_ _ If Referral,choose referral type(Fill one) <br /> Identifier: 27 V t GJrn O CHP Q CIWMB O Complaint O Educational Visit O Other ' <br /> Business or Facility NameInspe — <br /> cted By Inspector <br /> Physical Address <br /> rwn��tt C F.-ic C <br /> - <br /> Street I <br /> _. <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title OAM 0 AM <br /> al 0P ELI : <br /> 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count Whole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( ) f ® Active ( Passenger (a Generator Outdoor <br /> O O Closed C).Altered <br /> GPS Latitude tS Hauler 0Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - O Planned 0 OTR 0 End-Use Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q 0 14 CCR§18459.1 (a)(b)(c) Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§.18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments r <br /> yam-- f 7 0 y 317�7_ <br /> inspection Form Included 0 - <br /> • f I I <br /> Comments Included: -- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Forrect: Incorrect: (� ., ,� , P ;L I l <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />